CMS Releases Clarification on Special Status Calculation for Quality Payment Program

As if getting your head around the Merit-Based Incentive Payment System (MIPS) wasn’t challenging enough, CMS is now retracting an erroneous email sent in late July.

The email incorrectly stated that clinicians who qualify for “special status” would be fully exempt from the Quality Payment Program. Their latest guidance (sent in early August) corrects this error, stating that special status clinicians are not fully exempt from the program.

If you’re like most providers and the concept of special status has your head spinning, here’s a quick rundown on what it is and how it affects your MIPS participation.

What is “Special Status”?

As you may be aware, MIPS payment is determined by your performance (rated on a scale of 0-100) in each of 4 areas. Your performance score for each area is then weighted and used to calculate your performance composite score as follows:

CMS recognizes that you may not have enough patient or activity volume to fairly calculate a score in each area and has provided a “special status” for certain settings to ease some of the reporting requirements for measures, activities, or performance categories under the Quality Payment Program.

Who Qualifies?

Special status is only available to individual clinicians or practices who are otherwise required to participate in MIPS and are in one of the following settings:

Health Professional Shortage Area

Rural Area

Non-Patient Facing

Small Practice

Hospital-Based

How is Special Status Determined?

CMS uses your Medicare Part B claims data to determine whether you qualify for a special status designation. The calculations/requirements vary by setting as well whether you are an individual clinician or a practice.

According to CMS, the following criteria are used to determine your qualification for special status.

Health Professional Shortage Area (HPSA)

Individual: You practice in an “area designated under section 332(a)(1)(A) of the Public Health Service Act.”

Practice: Your practice has “at least one clinician that is designated as Health Professional Shortage Area.”

Rural Area

Individual: You practice in zip codes “designated as rural, using the most recent Health Resources and Services Administration (HRSA) Area Health Resource File data.”

Practice: Your practice has “at least one clinician that is designated as Rural.”

Practice: Your practice has “more than 75% of the NPIs under the practice’s TIN meeting the definition of an individual non-patient facing clinician during the non-patient facing determination period.”

Small Practice

Individual: The practice you are “billing under has 15 or fewer clinicians.”

Practice: Your practice has “15 or fewer clinicians billing under the practice.”

Hospital-Based

Individual: You furnish “75% or more of your covered professional services in the inpatient hospital, on -campus outpatient hospital, or emergency room settings (based on place of service codes) during the applicable determination period.”

Practice: “All clinicians associated with your practice are hospital based, provided that 75% or more of your practice’s covered professional services are furnished in the inpatient hospital, on -campus outpatient hospital, or emergency room settings (based on place of service codes) during the applicable determination period.”

How Does It Affect My MIPS Reporting?

Your MIPS reporting requirements will differ from the standard reporting procedures if you qualify for special status.

If you are in an HPSA, Small Practice, or Rural Area, special status provides you with an alternative for reporting Improvement Activity measures. To achieve the full 40 points available in this performance category, you may choose to report on a single activity that would then be worth the full 40 points or select two activities to measure that would each be worth 20 points.

For hospital-based and non-patient facing clinicians who meet the special status requirements, CMS allows you leeway on the Advancing Care Initiatives category. In fact, this category is weighted to zero for clinicians in both settings and does not count towards your Composite Performance Score.

Special Status for MIPS reporting is an opportunity for you and your practice to ease reporting requirements that could negatively (and unfairly) affect your Composite Performance Score and eventually your payment (by as much as 4% in the year 2019). You can check your eligibility and status in the MIPS program using this tool to ensure your Quality Payment Program reporting is accurate.

For more information on how you can protect your payments under MIPS and comply with MACRA guidelines check out these resources from Coding Leader’s MACRA library: